A total of 47 people died at the Herron long-term care home in the Montreal suburb of Dorval during the first wave of the pandemic in the spring of 2020.
The death toll was higher in other long-term care homes in the province and beyond, and many of the documented issues – a staff shortage, a lack of personal protective equipment – were also present elsewhere .
But the appalling conditions experienced by many 133 residents, detailed in reports in early April 2020, rocked the public and prompted broader questions about the state of the long-term care system in Quebec and across the country.
“What happened to Herron was not an isolated incident – it happened across Quebec and in every province of Canada,” said Moira Davies, whose father, Stanley E. Pinnell, is died in Herron, during the coroner’s inquest into the house.
Davis called for a national inquiry into senior residences and an end to private establishments.
The inquest into the deaths at Herron took place over three weeks and included testimony from nurses, doctors, local health authority officials, the owner of the private home and the families of the residents.
It was due to end on Thursday, but Coroner Géhane Kamel extended hearings after families of deceased residents said they still have questions after hearing conflicting testimony about what happened at home.
Three more dates will be added at the end of October to hear at least four other witnesses.
Here’s a look at what we’ve learned so far.
The crisis continued after the takeover of the health authorities
The first confirmed case of COVID-19 at home dates back to March 27, 2020.
Samantha Chowieri, the owner of the house, told the survey she called the local health authority, the CIUSSS of the West Island of Montreal, the next day for help, as the staff began to fall ill.
By the morning of March 29, many workers who were supposed to be on duty had left. Others had not shown up at all.
Local health authority officials said they found only a handful of employees on duty, the dark and quiet hallways, and residents without sufficient food and water.
From then on, the health authority got involved in the management of the establishment.
However, the poor conditions persisted until the beginning of April. A worker, whose name was subject to a publication ban, called the situation during the first week of “chaos”.
Even after the health authority took control, residents lacked basic care for several days, witnesses said. As of April 11, a total of 31 residents had died.
“I felt angry that we were told everything was under control, and yet people were still dropping like flies,” the same worker told the inquiry.
CIUSSS infection prevention specialist Nathalie Pigeon testified that she sent a member of her team to assess the measures at Herron on March 30, 2020. This inspection revealed many problems, including a shortage of disinfectant and washing stations. hands, and no indication of COVID-19 positive and non-COVID-19 patients.
Pigeon testified that she visited Herron for a follow-up on April 4 and found that most of the recommendations from the March 30 inspection had not yet been implemented. At this point, the entire building has been declared a red zone.
Bureaucratic tensions contributed to the problem
Questions lingered throughout the coroner’s inquest as to exactly why it has taken so long for the situation to improve. Kamel has often described the reason for the delays as a “black hole” in his investigation.
Several workers testified that officials at the local health authority and the residence were not on the same page as they tried to address staff shortages, access to patient records and lack of equipment, including personal protective equipment and basic medical equipment to measure oxygen levels. .
Emails presented as evidence showed a lack of cooperation between the health authority and the owners of the house, the Katasa group.
At one point, Kamel commented to a witness that his testimony gave the impression “that the people of Herron were staying in their offices, that the [regional health authority] remained in their offices, and that in the midst of it all, when there are little procedural fights, there are people dying. “
Deaths could have been prevented, worker says
The aim of the investigation, Kamel repeated throughout, was to determine whether the deaths at the home could have been prevented.
Alexandre Mercier, human resources worker at the the health authority, was frank on this point: if measures had been taken earlier, “we would perhaps have avoided a lot of deaths”.
Despite the odious situation inside the house, he was not asked until April 5 to recruit more staff, he said.
When asked why it had taken so long, Mercier said: “I think there were things to be clarified, namely what was our role, our responsibilities, maybe.”
The establishment was understaffed, disorganized
Staffing was an issue at home long before the pandemic. In fact, Herron lost many of his workers in the public system in January 2020 as a result of a recruitment drive.
At the time, Herron paid attendants $ 14 an hour, while the health authority offered them $ 20. Andrei Stanica, the manager of the house, turned to temp agencies to find workers.
Many of them had not been trained, which contributed to the mess at home leading to the pandemic, the investigation learned.
Marie-Ève Rompré, a the head nurse at St. Mary’s Hospital in Montreal who assisted at the home in early April 2020, said it was clear some residents had not received proper care during weeks. One resident in particular had not taken a bath since December 2019, Rompré said.
Hélène Paradis, chief pharmacist at the health authority, described how prescription drugs for residents were poorly organized and tidy when she arrived in April. She said she found open insulin vials and drugs in freezers with no dates marked, as well as drugs from 2017 or even earlier.
In their statements to the coroner, several families called for the end of private care homes.
Peter Barrette, whose father Léon died in Herron, told the survey the province should nationalize private long-term care homes to ensure that the primary purpose of the facilities is to “provide humane care” and not “to make a profit for the owners”.
Lynne McVey, CEO of the health authority, testified that in early April 2020, she became increasingly concerned about the situation at CHSLD Herron.
She said the health agency twice sent legal opinions asking the owner of the home, the Katasa group, patient medical records and information about Herron’s staff, but the requests were denied.
Reports brought about the change
A Montreal Gazette article by Aaron Derfel on April 10 was a catalyst for change at home, several witnesses said during the inquest.
Dr Lilia Lavallée, a doctor who had patients at the facility, said she came home the next day after reading the story and realizing “the extent of what was going on there.”
The coroner asked how she could not have known, given that other doctors had seen the situation with their own eyes and one of them had even brought in his family to help treat the patients.
“I tell myself that if this man [Derfel] had not written the article in the Gazette, would we have gone from 47 to 130 deceased residents? ” Kamel said.
McVey, the CEO of the health authority, called the police after the article was published. Kamel suggested the phone call was tantamount to a bit of “theater,” given that the health authority had been involved for over a week at that time.
After April 10, the CIUSSS recruited more staff and appointed a full-time care director.
Healthcare workers praised for their efforts
Despite the many problems at Herron, attendants, nurses and frontline physicians have told harrowing stories of doing their best to provide comfort and care to residents under difficult circumstances.
“I went into aid mode,” said Brigitte Auger, a health authority official who lent a hand. “I am not a practicing Christian, but I made the cross in my head, and I wanted to find a living person in every room.”
Following their testimony, Kamel often wanted to thank the witness for his work at the home.
“Rest assured that the coroner’s office does not blame health care workers”, Kamel said. “And each person who went to work, whether in a CHSLD or at the hospital, has nothing but thanks and respect from us.